In another packed room at EULAR 2017 this morning, the discussion on optimal management of early RA continued. We know that treating to target and rapid treatment escalation leads to improved outcomes in RA. We also mostly agree that methotrexate (MTX) should be part of initial RA treatment. What remains controversial is the initial dose and route of MTX, the appropriate use of glucocorticoids, and whether combination therapy should be started from the beginning.
Data from the METEOR cohort (observational international RA cohort with symptoms ≤5 yrs) looked at 6 month clinical outcomes in DMARD naïve patients based on their initial MTX treatment dose (≤ 10 mg, vs ≥15 mg weekly) and treatment strategy (monotherapy, combination therapy, biologic at onset). Interestingly, they found similar 6-month outcomes across groups, with no clinical benefit of using high-dose MTX, combination therapy, or concomitant glucocorticoid therapy at baseline.
Data from the UK national observational RAMS cohort were also presented which contradicted results from METEOR, but are more consistent with other published data. They looked at 6-month outcomes of 810 early RA patients, 21% of whom received MTX ≤ 7.5 mg/wk and 79% received ≥ 15 mg/wk. Their results showed that the higher initial dose of MTX increased the odds of having a good response at 6 months.
Data from the Netherlands compared outcomes in early RA using two historical RA cohorts, one in which patients received baseline methotrexate monotherapy and the other in which patients received baseline combination therapy (MTX, HCQ, triamcinolone). Results at 12 months showed DAS28 remission of 72% in the monotherapy cohort vs 88% in the combination therapy cohort. There was no difference in remission rates at years 2 and 3 between the cohorts, but the monotherapy cohort required 6% higher biologic use to achieve remission.
Finally, 2-year data from the CareRA trial were presented. Here, they evaluated only the high-risk early RA patients (erosions, RF/CCP +, high CRP) who were randomized to three treatment strategies including COBRA Classic (MTX/SSZ/Pred 60), COBRA Light (MTX/SSZ/Pred 30) and COBRA Avant-Garde (MTX/LEF/Pred 30). As was shown at 52 weeks, rates at 104 weeks were similar across the groups, at 65%, 73% and 73% for the three groups, respectively.
What did I learn? Well, the optimal treatment of early DMARD-naïve RA patients remains unclear, and most patients seem to do well as long as they are followed routinely and therapy is adjusted according to a target. However, aggressive early treatment (either with higher dose MTX plus or minus a combination) is associated with earlier remission and less use of biologics. We probably don't have to use very high doses of glucocorticoids since outcomes in COBRA Light patients were no different than on COBRA Classic.
Dr. Jamal is a Clinical Associate Professor at the University of British Columbia and an active staff physician at Vancouver Coastal Health. Her interests include diagnosis and prognosis of early inflammatory arthritis, and timely assessment and access to care for patients with rheumatoid arthritis.View Full Bio